521 Boxwood Church RdSo
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION °
*NOTE,;%Is�tjed in Compliance with G.S. of North Carolina Chapter 130 Article 13c
"Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ,� Prn rm Sj 2A -\V G IN Date - �2. - �.� NO 62f,'13
Location
Subdivision Name �` �' ," ...0 Lot No �Sec. or Block No
Lot Size House Mobile Home _� Business Speculation
No. Bedrooms rZ '` No. Baths No. in Family
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Machine YES ' B NO ❑ 1,
Type Water Supply
*This permit Void if sewag+ syst m described below is not installed within 36 months from date of issue.
44
G
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
0
b �
*The signing of this certifical
the standards set forth in the
satisfactorily for any givep•ITE
System Installed by
F
s . .
/ r
�Certificafe of Completion Date
t indicate that the system ,described above has been installed in compliance with
fe regulation, but shall in Nd way be taken as a guarantee that the system will function
of time. V'
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section REC'EtrED AN 17
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested
2. Address A e
Home Phone a
Business Phone
3. Property Owner if Different than Above )Euc PN c�0ruf-s
Address r TH-4, N ,Q .
4. Permit To: a) Install ✓ Alter Repair_
b) Privy Conventional V Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Bs
IndustryOther
b) Number of people
6. a} If house or mobile home, state size of ome and number of rooms.
House Dimensions A4, X �
Bed Rooms 0 Bath Rooms_ Den w/Closet 0
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes o2. urinals D garbage disposal a
lavatory 0 showers washing machine
dishwasher n sinks 3
8. a) Type water supply: Public `� Private Community
c—
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /�30 ee,5
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
ri_e�
Date I Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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ocr+o (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
11 d (office use only)
yes 0 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from EU -t,2 , owner to obtain a
wner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yei no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE IGNAT R
4. 1 hereby author .ze the Davie County ' Health Department to release site
evaluation Ifs from the above described property to the following:
res
Owner only
Owners designated representative
Anyone requesting results
Only those listed below
DATE o Sl. NATURE
DCHD (11 /84)
E
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O.. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
�� '�'�
Date
S
Address
PS
Lot Size
FAr:T()Ri4 APPA 1 AREA 9 APF: q� ARGA A
1) Topography/ Landscape PositionS
Q(S
S
PS
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 a i r}.o� pg-
S
PS
S
PS
S
PS
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Cly Soils
-M ��
PS
U
�y
U
PS
U
PS
U
1) Soil Depth (inches)
S
PS
(
LPS
S
PS
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
External
S
PS
S
S
PS
i) Restrictive Horizons
M
Available Space
csl
S
PS
PS
PS
U
U
U
U
o) Other (Specify)
S
PS
S
S
PS
S
PS
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE P tonally Suitable
Recommendations/Comments:
Described by �'�� Title Date 1
SITE DIAGRAM
DCHD (6.82)